A.

Scenario

A daughter, age 9 months, taken by his mother to the health center with complaints
of frequent diarrhea since one last month. A history of feeding: breastfeeding is given
up to 3 months, then given water until the starch now. Birth history: Birth Weight
2800 g, Body Lenght 47 cm. On physical examination found: Weight 3.4 kg, Body
Lenght 56 cm. Palms looked pale. Found bitot spot on eye, edema dorsum of the foot
and edema pretibial. Too it appears the wasting and baggy pants. Scores dehydration
13 and Hb 5 g / dl.

B. Diffiulct Word

Wasting
This is the most common form of acute malnutrition during a major food
shortage and, in its severe form, can quickly lead to death if untreated.
Baggy pants
When wasting is extreme, there are folds of skin on the buttocks and thighs. It
looks as if the child is wearing baggy pants.
Tajin water
Bitot Spot
Lack of vitamin A affects the development of goblet cells in the conjunctiva
resulting in accumulation of keratin debris.

C. Key Words

A daughter age 9 months

Diarrhea since one last month
A history of feeding : breastfeeding is given up to 3 months
Given water until the starch now
Birth history : Birth Weight 2800 g, Body Length 47 cm
Physical Examination : Weight 3,4 kg, Body Length 56 cm
Plams looked pale
Found bitot spot on eye, edema dorsum of the foot and edema pretibial
Too it appears the wasting and baggy pants
Score dehydration 1 and Hb 5 g/ dl
D. Questions

1. How is the interpretation of the baby is examination ?

2. What is the etiology of malnutrition especially PEM ?
3. What is the nutrition contents tajin water ?
4. What is the etiology and pathomechanism of diarrhea based on the scenario?
5. What is the etiology and pathomechanism of :
a. Baggy pants
b. Bitot spot
c. Edema pretibial and dorsum pedis
d. Wasting
e. Anemia
f. Dehydration
6. What is the correlation of the all symptoms ?
7. How to diagnose this scenario ?
8. What is the differential diagnose ?
9. How to treatment and education from scenario ?
10. How to preventation the others children ?
11. What is the prespective Islam according to scenario ?

E. ANSWER

1. How is the interpretation of the baby is examination ?

Answer :
Births weight 2800 gram, body length 47 cm.
On physical examination, weight 3,4kg, body length 56 cm.

Weight : 3400 gram

Babys weight gain occurred in 4 quarters : 2

Quarters I : 700 1000 gram/month

Quarters II : 500 6000 gram/month

Quarters III : 350 450 gram/month

Quarters IV : 250 350 gram/month

After we made a calculation :

The babys age is 9 months, so the babys weight gain : 7.450 8.150 gram
until the day arrived. The babys weight is not normal.

KMS CHART

Length : 56 cm

Babys length grow occurred in 4 quarters : 2

Quarters I : 2,8 4,4 cm / month

Quarters II : 1,9 2,6 cm / month

Quarters III : 1,3 1,6 cm / month

 Quarters IV : 1,2 1,3 cm /month

After we made a calculation :

The babys age is 9 months, so the babys length grow : 74 81,8 cm until the
day arrived. The babys length is not normal.

B. WHO CHART

Graph nutritional assessment over by age group

Age Graphic Used

Birth 5 years WH0 2006

For more nutritional status and

obesity see sticky-master below.
>5-18 years CDC 2000
Determination of nutritional status using a cut off Z score WHO 2006 for ages
0-5 years and the percentage of ideal body weight according Waterlow criteria
for children over 5 years.
Interpretation of z-scores for weight for age curve who are: 1

between 1 to -2SD called weight according to age

below -2 SD called less weight (underweight)
below -3 SD called weight is less( severely underweight)
Interpretation of z-scores for height for age:1

between -2 SD and 2 SD called height according to age

below -2 SD called short (stuned)
below -3 SD called a very short (severely stuned)

2. What is the etiology of protein energy malnutrition ?

Answer :
Marasmus
Etiology : Primary causes : Marasmus may be dietary in origin. This is the
most common cause observed in children in the the developing countries of
the world. It stems from an inadequate diet, both qualitivatevky and
quantitevely. Most infants who suffer from marasmus are fed artificially with
over diluted formulae. They suffer from infections such as gastro-enteritis.
They belong to poor socio-economic groups and parents lack of education is
often a contiributory factor.
Secondary causes : the following factors can contribute to this condition, the
last two in the list below being far less important than the first five.

1) Age : marasmus is much more common infants than in older children.

This is particularly true of premature babies. A premature infant or an
infant with a low birth weight may take time to catch up with healthier
infants and may appear marasmic in the meanwhile. This could be due to
the high energy requirements of infants and also to the rapid wasting that
can occur in a short period of time due to dietary deficiency. Older
children may take longer to develop a marasmic state because of their
lasser caloric requirements. Howevwer, it has been shown than evem
adults can evelop PEM if the essential causative factors operate.
2) Chronic vomiting from any cause can lead marked wasting. The vomiting
may be due to congenital hypertonic pyloric stenosis. Unless treated
promptly and energetically, this can and does leas to undernutrition and
marasmus in the first few months of llife. Other less frequent causes of
chronic vomiting, such as chalasia of the cardia, i.e relax ed cardiac
sphincter, diagpharmagmatic hernia, etc can result in marked wasting.
Rumination is rare but can lead to marked underweight in older infants
3) Repeated episodes of chronic dirrhoea lead to loss of weight and
marasmus because the baby is kept too long a low-calorie diet like
arrowroot fruel. Besides, the digestion and absorption of nutrients is
impaired during and after diarrhoe, especially when there are reperated
bouts.
4) Chronic infections, e.g. congenital syphilis, chronic empyema thorachis,
tuberculosis, upper respiratory infection, etc can cause wasting. Besides,
the marasmicinfants is readily probe to infection (of the aer, lungs, skin,
 bowels, etc) and reacts poorly to them. The wasting than becomes
aggrevated.
5) Congenital disease limit the intake and digestion of food, e..g, cleft oalate,
micrognathia hydrocephalus, congenital renal disorders, Hirschsprungs
disease, etc.
6) Serious organic disorders of heart, brain and kidney can causes a failure
og growth. Coeliac disease and mucoviscodiosis, both rare in the tropics,
lead to wasting because of the failure of digestion.
7) Certain metabolic disorders produce a disturbance in nutrition. Marasmus
may be present in infantile renal acidosis. Diabetes rarely occurs in
infants. Galactosemia may lead to nutritional failure often associated with
vomiting.

Kwashiorkor

1) The non availability of suirtable protein-rich foods for feeding infants and
children because of socio-economic and agronomical factors seems to be
the main cuase. Animal-protein foods like milk, meat, eggs and fish are
rarely consumed by children of the poorer classes because of the high cost.
For example, a supply of 10 g of animal protein would cost about a rupee,
while vegetable sources like roasted groundnut or Bengak gram would
cost about fifty paise. Several surveys of wearning food habits in South
India among the poorer classes have rrevelated that in most instances, the
amount of cos or buffalos milk consumed by children is below four
oz/day, and that hardly any meat is included in the diet. Poverty is an
overwhelmingly predisposing factor to malnutrition. The poverty index
( espreed in terms of deficient caloric intake ) indictes that as much as 70
percent of Indians exist below the poverty line
2) Faulty feeding habits arise from ignorance, prejudices and superstions.
The late instution of supplementary feeding is common in many
 communities. Even the choice of supplementary food is often limited to a
portion of the adult cereal diet, hardly any pulses and no animal foods.
3) Prolonged breastfeeding : in India and Africa, prolonged breast feeding of
infants even up to the third year is quite common. No doubt such milk
supplies some protein and may well protect the child against protein and
may well protect the child against protein malnutrition. But the quantity of
milk supplies some protein and may well protect the child against protein
malnutrition. But the quantity of milk is inadequate and prolonged sucking
at the breast tends to encourage the child to take very small amounts of
solid food or even to refuse it. Prolonged breast feeding actually leads to
breast and diction and aggravates malnutrition.
4) Infections and infestations : poverty, ignorance, poor sanitation and
oevercrowding in slums owing to increasing urbanization are responsiavle
for precipitating infections and infestations. In an already undernutrition.
This lowers the resistance, which in turn aggravates the risk of infection.
5) A sudden loss of protein or a sudden demand for an increased amount of
protein are important precipitating causes in kwashiorkor. Prolonged
breast feeding without nutritional supplements leads to malnutrition.
When breast feeding is suddenly withdrawn because of another pregnancy,
the child does not get eve the minimal quantity of good quality animal
protein which he has being. This sudden loss of protein supply, in addition
to emotional deprivation, precipitates kwashiorkor. As the fetus utero
idislaces this child, this condition is known as the deposed child or
dispaced child syndrome. Similarly, in an already undernourished child,
a sudden illness, like the onset of measles, responds favourably only tto
extra protein, and when this is not available kwashiorkor result
6) Seasonal incidences : in India, the peak incidence of kwashiorkor
corresponds to the months when the largest number of infective diarrhoeal
cases occur. Diarrhea and a decrease in the intake and digestion of food
precipitates kwashiorkor.
 7) Size of family : this has a direct relationahip to the nutritional status of
children. In families where there are more than four or five children, the
incidence is 2-3 times more.

Marasmic Kwashiorkor
Causemarasmic - kwashiorkor can be divided into two causes are malnutrition
primary and secondary malnutrition.
1) The primary malnutrition is malnutrition caused by the intake of protein
and energy is inadequate. This is because of poverty, the composition of
improper diet, alcoholism, drug addiction, food allergies, do not eat,
idiosyncrasy (abstain from eating certain foods), fad diet (unhealthy food),
and others that can make the intake is inadequate.
2) Secondary malnutrition is malnutrition that Occurs because of the
Increased need, reduced absorption and / or an increase in loss of protein
and energy of the body. 3

3. What is the nutrition contents tajin water ?

Answer :

Water starch is just water boiled rice and contain no nutrients other than
carbohydrates. Water starch is white liquid chewy which is obtained when
cooking rice.4

Nutrient content in water starch in general is: 4

Component Total
Energy (Kal) 43,20
Water (g) 91,21
Protein (g) 0,66
Fat (g) 1,92
 Carbohydrate (g) 5,82
Vitamin B1 (mg) 0,0046
Fe (mg) 0,086

4. What is the etiology and pathomechanism of diarrhea based on the scenario?

Answer :
Stool is 60 to 90% water. In Western society, stool amount is 100 to 200 g/day
in healthy adults and 10 g/kg/day in infants, depending on the amount of
unabsorbable dietary material (mainly carbohydrates). Diarrhea is defined as
stool weight > 200 g/day. However, many people consider any increased stool
fluidity to be diarrhea. Alternatively, many people who ingest fiber have
bulkier but formed stools but do not consider themselves to have diarrhea.

Normally, the small intestine and colon absorb 99% of fluid resulting from
oral intake and GI tract secretionsa total fluid load of about 9 of 10 L daily.
Thus, even small reductions (ie, 1%) in intestinal water absorption or
increases in secretion can increase water content enough to cause diarrhea.
There are a number of causes of diarrhea. Several basic mechanisms are
responsible for most clinically significant diarrheas: increased osmotic load,
increased secretions, and decreased contact time/surface area. In many
disorders, more than one mechanism is active. For example, diarrhea in
inflammatory bowel disease results from mucosal inflammation, exudation
into the lumen, and from multiple secretagogues and bacterial toxins that
affect enterocyte function.

Osmotic load
Diarrhea occurs when unabsorbable, water-soluble solutes remain in the
bowel and retain water. Such solutes include polyethylene glycol, Mg salts
(hydroxide and sulfate), and Na phosphate, which are used as laxatives.
Osmotic diarrhea occurs with sugar intolerance (eg, lactose intolerance caused
by lactase deficiency). Ingesting large amounts of hexitols (eg, sorbitol,
mannitol, xylitol) or high fructose corn syrups, which are used as sugar
substitutes in candy, gum, and fruit juices, causes osmotic diarrhea because
hexitols are poorly absorbed. Lactulose, which is used as a laxative, causes
diarrhea by a similar mechanism. Overingesting certain foodstuffs can cause
osmotic diarrhea. In colon, these lactose will be fermentated by bacterial
anaerob become smaller molecules, such as H2, CO2, H2O, and others. It will
increase the osmotic pressure in loop of intestine. The hiperosmolar situation
will cause the moving of water and electrolytes to the loop of intestine. It will
increase the peristaltic of intestinal and causing diarrhea.

Increased secretions
Diarrhea occurs when the bowels secrete more electrolytes and water than
they absorb. Causes of increased secretions include infections, unabsorbed
fats, certain drugs, and various intrinsic and extrinsic secretagogues.

Infections (eg, gastroenteritisdiscussed in Gastroenteritis) are the most

common causes of secretory diarrhea. Infections combined with food
poisoning are the most common causes of acute diarrhea (< 4 days in
duration). Most enterotoxins block Na+-H+ exchange, which is an important
driving force for fluid absorption in the small bowel and colon. After
colonization, enteric pathogens may adhere to or invade the epithelium; they
may produce enterotoxins (exotoxins that elicit secretion by increasing an
intracellular second messenger) or cytotoxins. They may also trigger release
of cytokines attracting inflammatory cells, which, in turn, contribute to the
activated secretion by inducing the release of agents such as prostaglandins or
platelet-activating factor.
Unabsorbed dietary fat and bile acids (as in malabsorption syndromes and
after ileal resection) can stimulate colonic secretion and cause diarrhea.

Drugs may stimulate intestinal secretions directly (eg, quinidine, quinine,

colchicine, anthraquinone cathartics, castor oil, prostaglandins) or indirectly
by impairing fat absorption (eg, orlistat).
Various endocrine tumors produce secretagogues, including vipomas
(vasoactive intestinal peptide), gastrinomas (gastrin), mastocytosis
(histamine), medullary carcinoma of the thyroid ( calcitonin and
prostaglandins), and carcinoid tumors (histamine, serotonin, and
polypeptides). Some of these mediators (eg, prostaglandins, serotonin, related
compounds) also accelerate intestinal transit, colonic transit, or both.

Reduced contact time/surface area

Rapid intestinal transit and diminished surface area impair fluid absorption
and cause diarrhea. Common causes include small-bowel or large-bowel
resection or bypass, gastric resection, and inflammatory bowel disease. Other
causes include microscopic colitis (collagenous or lymphocytic colitis) and
celiac disease.
Stimulation of intestinal smooth muscle by drugs (eg, Mg-containing antacids,
laxatives, cholinesterase inhibitors, SSRIs) or humoral agents (eg,
prostaglandins, serotonin) also can speed transit.

Pathomechanism of Diarrhea based on Scenario

Protein in the small intestine which is dipeptida form hidrolized by peptidase
enzyme from epitel cell of small intestine, that will produce many kind of
dipeptida and small polipeptida. And then, it will be hidrolized again by
aminopolipeptidase enzyme and dipeptidase become amino acid. Next process
in the small intestine is the absorbtion of all substances in the small intestine
 that specifically happen in vili. The substances will be absorbed in a simple
form. But there are certain proteins that can not be digested due to its physical
and chemicals structure. It will disturb the absorption process and cause the
atrophy of mucous in small intestine. The side effect of nutrition feeding other
than ASI for < 6 months baby often cause diarrhea. It may occur because the
digestive system of the baby not ready enough and can not sufficiently work,
so they can not digest nutrition besides ASI. The increase of solute load of
other nutritions also can cause hiperosmolarity that will increase the peristaltic
and causing diarrhea. And also, one of the risk factor is the way of feeding
that may not too higiene and cause infection of microorganism. After
colonization, enteric pathogens may adhere to or invade the epithelium; they
may produce toxins. They may also trigger release of cytokines attracting
inflammatory cells, which, in turn, contribute to the activated secretion to the
loop of intestine. It will also generate hiperosmolarity and hiperperistaltic that
will cause diarrhea. 5,6

5. What is the etiology and pathomechanism of :

a. Baggy pants
Answer :
Severe wasting
A child with severe wasting has lost fat and muscle and has a skin and
bones appearance. Another term used for this condition is marasmus. Severe
wasting in infants of under 6 months is marked by visible severe wasting.
Whereas for children >6 month severe wasting is assessed objectively using
anthropometric measurements (WFL/H, MUAC).

Visible severe wastingis an important sign of SAM for infants under 6 months
of age. It is used as a criteria to classify as SAM only for infants below 6
months age. To look for severe wasting, remove the childs clothes. Look at
the front view of the child:
 Is the outline of the childs ribs easily seen?
Does the skin of the upper arms look loose?
Does the skin of the thighs look loose?
Look at the back view of the child:
Are the ribs and shoulder bones easily seen?
Is flesh missing from the buttocks?
When wasting is extreme, there are folds of skinon the buttocks and thighs. It
looks as if the
child is wearing baggy pants. Because a wasted child has lost fat and
muscle, this child will weigh less than other children of the same height/length
and will have a low weight-for-height/Length. 7

b. Bitots Spot
Answer :

Eponymsed after Charles Bitot who first described them, Bitot's spots
represent an ocular manifestation of VAD. VAD is an important cause of
preventable blindness in the developing world. Clinical detection of Bitot's
spots affords an opportunity for early diagnosis of VAD. Although VAD may
have disappeared in the developed world, the condition is still common in the
developing world. Since determination of levels of serum retinol are not
available routinely ocular features ranging from night blindness, conjunctival
xerosis and corneal xerosis, Bitot's spots and corneal ulceration and scarring
may provide clinical clue to the diagnosis.

Lack of vitamin A affects the development of goblet cells in the

conjunctiva resulting in accumulation of keratin debris. The Bitot's spots also
demonstrate keratinization, irregular maturation, inflammatory infiltration and
accumulations of Gram-positive bacilli.Generally seen as triangular spots, the
Bitot's spots usually have the tip laterally and may have a variable surface.
These may be foamy and cheesy whitish lesions and are the most common
indicator used to estimate VAD in community. Bitot's spots are usually due to
nutritional VAD which is a common public health problem among preschool
children in the developing world. Other conditions associated with systemic
avitaminosis A may include reduced intake (alcoholism, mental illness, and
dysphagia), disordered absorption (Crohn's disease, celiac sprue, pancreatic
insufficiency, and short bowel syndrome), disordered transport
(Abetalipoprotenemia) and reduced storage (liver disease). The clinical
detection of Bitot's spots confirms VAD. Confirmation may be done by
estimation of serum retinol or retinol binding protein levels. The efforts
should be directed to evaluate the cause of VAD including reduced intake or
any malabsorptive state. In the present case, a diagnosis of celiac sprue was
established and patient put on gluten free diet with improvement in form of
normal stool frequency and a gain of height and weight. The IgA tissue
transglutaminase at 6 months was 3.8 U/mL.8

c. Edema pretibial and dorsum pedis

Answer :
PEM resulting in a decrease in the osmotic pressure due to decreased
levels of albumin. 9

Mechanism 9
H
y
pP
or
ao
lt
be
ui
mn
iI
nn
et
ma
ik
ae
d. Wasting
Answer :
A rapid decline in nutrition can lead to wasting This is the most common form
of acute malnutrition during a major food shortage and, in its severe form, can
quickly lead to death if untreated. It is characterised by severe wasting of
body fat and muscle, which the body breaks down to make energy. A wasted
childs body tries to conserve as much energy as possible by reducing physical
movement and growth, restricting bodily processes and shutting down the
immune system. This reduced activity results in limited function of the liver,
kidney heart and gut, putting the child at risk of low blood sugar, low body
temperature, infection and heart failure. Children who suffer from wasting
face a markedly increased risk of death. 10
e. Anemia
Answer :
Etiology
This vitamin is known as the guardian of appetite and prevent anemia
(lack of blood) to form red blood cells. Because of its role in the formation
of cell, cobalamin deficiency can interfere with the formation of red blood
cells, causing a reduction in the number of red blood cells. As a result, cases
of anemia. Symptoms include fatigue, loss of appetite, diarrhea, and moody.
Severe B12 deficiency causes potentially fatal form of anemia called
Pernicious anemia. The body needs vitamin B12 as important as iron
minerals. Vitamin B12 is jointly iron serve as a red blood formation.Even the
deficiencies are not only lead to anemia, but can disrupt the nervous system.
Vitamin B12 deficiency can occur due to interference from within our own
bodies or external causes. Gastrointestinal tract will absorb all the nutrients
in foods, including vitamin B12. Lack of vitamin B12 someone less blood
(anemia). characterized by diarrhea, slippery tongue. Folic acid can be
obtained from meat, green vegetables, and milk. Poor nutrition
(malnutrition) is the main culprit. 11

Mechanism
Anemia occurs due to disruption due to the maturation of the cell
nucleus DNA synthesis disruption eritroblas cells. Defisienasi folic acid
would interfere with the synthesis of DNA to the cell nucleus maturation
interference occurs with the consequent emergence of cells megaloblasts.
Vitamin B12 deficiency which is useful in the methylation reaction
homosisten into methionine and this reaction was instrumental in changing
the methyl THF into DHF role in DNA synthesis and would disrupt the
maturation of the cell nucleus, causing more megaloblasts
 The basic cause of the absorption of vitamin B12 abnormality is
atrophy of the gastric mucosa that fail to excrete fluid lambumg mucosa of
the stomach. In normal circumstances, the parietal cells in the gastric glands
excrete a glycoprotein called intrinsic factor which joins with vitamin B12 so
that vitamin B12 can be absorbed, and subsequently developed the following
stages: 11

1. Intrinsic factor binds closely with vitamin B12. In the bound state, Vitamin B12 is
protected from digestion by gastrointestinal enzymes.

2. Still a bound state, intrinsic factor binds to a specific receptor located on the edge of
the mucous membrane in the ileum.

3. Vitamin B12 is transported into the blood during the next several hours through the
process of pinocytosis, which transports intrinsic factor and vitamin together across
the membrane. Therefore, when the intrinsic factor is not there then benyak vitamin is
lost (including vitamin B12) for the work of digestive enzymes in the intestine and
absorption failure

f. Dehydration

Answer :

Etiology

Dehydration occurs when the body's discharge greater than the intake.
Lack of fluids usually causes calcium levels in the blood increase. Some
things that can lead to dehydration: 12
 1. Vomiting

2. Diarrhea

3. The use of diuretics (drugs that cause the kidneys to excrete large
amounts of water and salt)

4. Excessive heat

5. Fever

6. Reduced intake of fluids for a variety of reasons

7. Lack of Sodium

8. Lack of Water

Mechanism

Water loss due to acute diarrhea leads to dehydration that can be mild,
moderate or severe. In acute diarrhea, dehydration is a symptom of imminent
due to recurrent fecal discharge. Dehydration occurs due to loss of water and
electrolytes that exceed revenues. 12

6. What is the correlation of the all symptoms ?

Answer :
a Diarrhea
Diarrhea in infants associated with starch water consumed by infants from 4-9
months of age. Water is the essence of rice starch with a creamy texture
obtained when cooking rice. Air starch can not be given to infants under 6
months because the baby's digestive system is not perfect, so the baby can not
yet accept well. The protein in the small intestine in the form of dipeptide is
hydrolyzed by the enzyme peptidase of the epithelial cells of the small
intestine into various dipeptide and small polypeptides. Furthermore, it would
be hydrolyzed by the enzyme aminopolipeptidase back and dipeptidase into
amino acids. The next process that occurs in the small intestine, the absorption
of substances in the intestine that specifically occur in the villi and depend on
diffusion, a facilitative diffusion, osmosis, and active transport. Most of these
substances are absorbed in a simpler form. In water starch, protein content is
not sufficient for the baby, so that the small intestine does not occur
absorption and cause mucosal villous atrophy of the small intestine that can
cause diarrhea in infants.
Giving complementary foods too early can result in babies more often suffer
from diarrhea. This is due to the formation of antibodies by the baby's gut is
not perfect and perhaps also to prepare food that is less clean. Baby is allergic
to certain food substances. This occurs due to the baby's intestine is
permeable, so easily traversed by foreign proteins. Before reaching the age of
6 months of the baby's digestive system is not able to function perfectly, so he
has not been able to receive food other than breast milk. 13

b. Edema
Edema in the scenario of insufficient protein intake, resulting in shortages of
essential amino aam serum required for the synthesis and metabolism. More
reduction in serum amino acids will cause lack of hepatic production of
albumin, albumin which serves to maintain the osmotic pressure of plasma.
Decreasing the concentration of plasma proteins cause a decrease in plasma
osmotic pressure. This leads to a decrease in filtration discharge from
capillary blood vessels is higher, while the amount of fluid is reabsorbed less
than normal, so there is additional fluid is left behind diruang-interstitial
space. Fluid will then fill the sidelines of loose connective tissue and the body
cavity. In addition, the liquid will follow the force of gravity so that the
scenarios contained in the leg edema. 14

c. Bitot spot
Bitot spot cause due to deficiency of vitamin A. Vitamin A deficiency can
occur at any age but ekurangan are accompanied by abnormalities in the eye is
generally found in children aged 6 months to 4 years. One pearuh that occurs
in the eye is a change in the eye. Vitamin A deficiency can lead to
abnormalities in the epithelial cells of the mucous membranes of the eyes.
Abnormalities such as the process of metaplasia of epithelial cells, so that the
gland does not produce a fluid that can cause dryness of the eye called
conjunctiva xerosis. When this condition persists there will be painted bitot
(Bitot spot) is a white spot, triangular temporal and covered by material such
as foam. 15

Pathomechanism of Anemia
Changes in hematologic system at cases of malnutrition include anemia,
leucopenia, trombotopenia, pembentuan akantosit, and hypoplasia of the bone
marrow cells associated with the transformation of the substance dasa, where
necrosis is often seen. This abnormality degree depending on the severity and
duration of ongoing energy shortage (Sunita Matsier, 2009)

Anemia in such cases is usually accompanied by normokromik andnot

reticulocytosis although quite adequate iron stores. The cause of anemia
patients whose protein intake is inadequate erythropoietin synthesis is
declining, while anemia in those who did not eat protein arising from stem
cells in the bone marrow does not develop, in addition to erythropoietin
synthesis also decreased. This situation would then give look these pale in
malnourished patients. 16
 Wasting and Baggy Pants
Due to intake of inadequate nutrition on protein energy malnutrition, every fat
stored in the muscle as food reserves will continue to be broken, until the fat
in the subcutaneous tissue also will participate split, consequently it can cause
fat reserves become increasingly smaller until no , this condition will give
Tampakan as sagging pants on the buttocks due to the amount of fat that can
not maintain the consistency subcutaneously. 17

7. How to diagnose this scenario ?

Answer :
Assessment of nutritional status of routine and detailed as part of the
assessment of the plenary in pediatric patients, which is absolutely necessary
in elderly patients, including history, physical examination, inspection
anthropometric, examination of biochemical markers and assessment of
elderly at risk of malnutrition by using the tools that have been validated.
Assessment of nutritional status is not easy due to age-related changes in body
composition and function decline that resembles the changes due to
malnutrition.
Throughout the world malnutri is one of the major causes of morbidity
and mortality in childhood. Malnutrition can result from improper food intake
or Insufficient or may result from inadequate food uptake. Provision of food is
not enough, bad dietary habits, fashionable food and emotional factors can
limit input. Basic nutrient requirement may be increased during stress and
illness as well as during the administration of antibiotics or drugs catabolic.
Malnutrition can be acute, chronic, reversible or not. 18
Evaluation of proper nutrition status is difficult. Impaired weight
easily visible but mild disorders can be passed, despite inspections after a
physical examination and laboratory throughput. Nutritional assessment
comprehensively covers: 18
1. History taking (anamnesis)
2. Physical examination
 3. Examination of anthropometric
4. Supporting examination

a. Anamnesis
Diagnosis is based on history dietetic malnourished children right,
it had suffered, the economic status of parents and the state of the socio-
economic environment. With this history we also distinguish whether the
child is suffering from malnutrition, primary or secondary.

b. Physical examination
i. Inspection: easily pull hair, delicate, fragile, hypopigmentation,
depigmentation. Eyelashes long and tapering, moon face, old man's face,
pale, thin. Edema and ascites. Crazy pavement skin dermatoses.
ii. Palpation and percussion: pitting edema, liver enlargement
(hepatomegaly). 18

c. Examination of anthropometric
Antopometrik examination is one of the integral part of a series of
nutritional status assessment. The assessment was performed to examine
tissue terkatabolisasi body during starvation / starvation or stress state,
namely the muscle, fat and visceral protein reserves. This examination is
an examination that is not expensive can be used to determine a person's
nutritional status of both short- and long-term common. On the evaluation
of anthropometric deviation of weight, height, head circle on average, the
rate of growth; the comparative measurement of the circle and the
thickness of the skin in the midst of the upper arm, upper arm
circumference. Decrease in skin fold thickness gives the impression
malnutrisinprotein calories; Excess thickness indicates obesity. Muscle
mass is calculated by subtracting the upper arm circles to measure skinfold
thickness. To circle the upper arm muscles amid children and adults (cm)
 = arm circles over the middle (cm) - (skinfold thickness [cm] x 3.14).
Lean body weight can be estimated from 24-hour creatinine excretion. 18

d. Supporting examination
Laboratory examination
i. Biochemistry of blood (serum albumin and transferrin) will generate
data that help with the diagnosis of micronutrient deficiencies and
protein. The measurement results prealbumin or transferrin is more
appropriate to assess a person's status changes of proteins in a short
time when compared to the results of measurement of albumin. This is
caused by age prealbumin much shorter (2 days) than age albumin (18
days). The following comparison table malnutrition rates by levels of
albumin and transferrin. 18
Albumin Serum Transferin Serum
(gm/dL) (gm/dL)
Mild Malnutrition 3,0 3,5 1,5 2
Moderate Malnutrition 2,1 3,0 1 1,5
Severe Malnutrition < 2,1 <1

With a chemical test, a deficiency of some nutrients can be shown with

high levels of nutrients or their metabolites in the blood is low, by
observing the effect of biochemical or effect of nutrients or products in
the clinic, or by giving the patient a large number of nutrients
appropriate and consider the numbers excreted. Backup protein judged
from serum albumin and protein replacement rate. Levels of protein
replacement fast, transthiretin with a half-life 12 hours, prealbumin
with a half-life of 1.9 days and transferrin with a half-life of 8 days,
declined for visceral protein synthesis is not sufficient or because the
emptying of protein deposits. Serum levels of essential amino acids
may be lower than serum levels of nonessential amino acids.
 Hydroxyproline excretion decreased and 3-metilhistidin rose, and the
hair easily lifted in severely malnourished children. 18

ii. Electrolyte

The most acute nutritional disorder is a disorder that involves water

and electrolytes, particularly sodium ions, potassium, chloride and
hydrogen. Chronic malnutrition usually involve more than one nutrient
deficit. Immunological insufficiency often exist in malnutrition and
TLC indicated by the number that is less than 1500 / mm3 and energy
to the skin test antigens, such as streptokinase-streptodornase,
Candida, mumps, or tuberculin in people exposed.

iii. Peripheral blood, namely blood glucose (hypoglycemia) and

hypoalbuminemia.

iv. Blood smear with a microscope or direct detection test

v. Hemoglobin to assess anemia.

vi. Fecal smear with a microscope to determine the presence of ova

and parasites as the cause of the diarrhea.

vii. Anatomic pathology to assess the accumulation of fat in the liver

that can provide clinical form of hepatomegaly.

viii. Radiological examination should also be conducted to find

abnormalities in the lungs. 18

8. What is the differential diagnose ?

Answer :
Marasmus is nothing but a severe form of malnutrition. The disease is
generally seen in the infants. Marasmus is caused due to severe loss of chronic
waste of fat, muscles and other tissues of the body. The disease occurs due to
shortage of basic nutrition, proteins, vitamins and calories to the body.
Marasmus is a serious problem and is commonly detected in the developing
regions like Africa, Latin America and south Asia. The disease is also
commonly known as kwashiorkor.

Symptoms of Marasmus:
The symptoms of marasmus often depend upon the degree of malnutrition.
Following are some of the symptoms of marasmus:
Chronic diarrhea
Dizziness
Fatigue
Severe weight loss
Change in level of consciousness
Paralysis of legs
Loss of bowel and bladder control
Prolonged vomiting
Diarrhea
Lethargy
Delay in healing of wounds
Distended abdomen
Hypotonia
Muscle atrophy
Growth retardation

The loose skin folds and loss of adipose tissues are the other common
symptoms of marasmus.

Causes of Marasmus:
The main cause of marasmus is malnutrition. Following are some of the other
causes of marasmus:
 Poverty
Inadequate food supplies
Contaminated water
Deficiency of vitamin A,E and K
Poor and unbalanced diet

The other important causes of marasmus include the metabolic changes,

anatomic changes, etc.
Diagnosis of Marasmus:
Following are some of the diagnosis methods of marasmus:
Serum albumin level test
Urinary creatinine test
Body weight with respect to height
Skin tests

The above mentioned tests and the symptoms detected in the patient help in
the diagnosis of marasmus.
Treatments for Marasmus:
Following are some of the treatments for marasmus:
Vitamin B5 treatment
Treatment for hypoglycaemia
Treatment for hypothermia
Treatment for dehydration
Treatment to overcome electrolyte imbalance
Treatment for any infections

During the treatment, the patient is provided with the required proteins,
vitamins, minerals and fats.
Complications of Marasmus:
Following are some of the complications of marasmus:
Abnormality of tongue
Hypo pigmentation
Weight loss
 Immune deficiency
Reduction in red cell production

The complications may also include muscle wasting, muscle weakness and
short stature. 19

9. How to treatment and education from scenario ?

Answer :

Treatment

Oral rehydration solutions

Oral rehydration solutions ( CRO ) or known as ORS is specially

packaged liquid , containing water and electrolytes are used to prevent and
treat dehydration during diarrhea .

Zinc tablets given for 10 consecutive days

Zinc proven scientifically reliable can decrease the frequency of bowel

movements and the volume of stool so that it can reduce the risk of
dehydration in children .

Forward -fed breast milk

ASI and food with the same menu when healthy children according to age
still given to prevent weight loss and as a substitute for the missing
nutrients .
 Give antibiotics selectively

Antibiotics are given when there are indications , such as dysentery

(bloody diarrhea ) or cholera. Antibiotics are not rational would disrupt the
balance of intestinal flora

Provide advice to the mother / family

Education
Parents are asked to bring the child back to the Health Care Center
when it is found the following: fever , bloody stools , eating or drinking a
little , very thirsty , diarrhea more often , or not improved within 3 days .
Parents and caregivers are taught how to prepare ORS correctly .
Step promotive / preventive : 20

1. breast milk is given

2. personal hygiene , wash hands before eating

3. environmental hygiene, defecate in latrines

4. immunization against measles

5. provide true weaning foods

6. the provision of clean drinking water

7. is always cooked meal.

10. How to preventation the others children ?

Answer :
Step Promotive / Preventive
Protein energy malnutrition is multifactorial nutritional problems .
Preventive measures aimed at reducing the incidence and reduce mortality.
Therefore there several factors are causing the problem , then to prevent it
to do several steps , among others : Diet 21

Conseling on about nutrition balanced ( Ratio of the

amountcarbohydrates , fats , protein , vitamins and minerals based on
age and weight )

Monitoring growth and nutritional status determination periodically

( once a month in the first year

social factors seek the possibility of restrictions on use of certain

foodswhich has lasted for generations and can cause MEP

Economic factors

In the World Food Conference in Rome in 1974 has been stated that
the increasing number of people are fast being offset by increasing
local food supplies Adequate is the major cause of food crisis, while
the population is due to the continuation of poverty . It also stressed
the need for good nutritious food in addition to quantity. Factor
Factors infection. It has long been known the existence of a synergistic
interaction between the MEP and infection .

Infection degrees whatever may worsen the nutritional status .MEP ,

although in mild degree , lowering the body's resistance to infection .
 11. What is the prespective Islam according to scenario ?
Answer :
Among them are also passages that speak of the rights of children to get
the milk, as Allah the Exalted: 22

{233 : }

"Mothers shall suckle their children for two full years, that is for those
who want to enhance breastfeeding. And the obligation to feed and clothe
the father to the mother with kindness. Someone not burdened but
according to levels of ability. No mother suffered misery for her son and a
father for his son, and heir shall be chargeable case. If both want wean
(before two years) with both willingness and consent, there is no blame on
either of them. And if you want your son disusukan by others, then there is
no sin on you if you make the payment according to the worth. And fear
Allah and know that Allah is All-Seer of what you do "(QS. Al-Baqarah:
233). 22

Daftar Pustaka
1. Prof. Soetjiningsih, Dr., Sp.A(K). Tumbuh Kembang Anak. Ed.2. Jakarta.
EGC. 2015.
2. Diktat kuliah. Dr.dr.Martira Maddeppungeng, Sp.A (K).FK UMI. 2016
3. J.Viswanathan. Achars Textbook Of Pediatrics. 3rd Edition.Orient Longman.
4. Kristiyanasari, Weni.2011. Asi, Menyusui Dan Sadari. Yogyakarta: Nuha
Medika
5. http://emedicine.medscape.com/article/diarrhea
6. http://www.merckmanuals.com/professional/gastrointestinal-
disorders/symptoms-of-gi-disorders/diarrhea
7. Yifru, Belaynesh dkk. Training Course On The Management Of Severe Acute
Malnutrition. 2013. ETHIOPIA Ministry of Health : Addis Ababa. [diakses
tanggal 5 mei 2016] URL :
http://www.cmamforum.org/pool/resources/ethiopia-participant-manual-jul-
2013.pdf
8. Sharma, Alka dkk. 2014. Bitots Spots : Look At The Gut. Department of
Medicine, Government Medical College and Hospital : Channdigarh. [diakses
tanggal 5 mei 2016] URL :
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258671/
9. Effendi, Ian danRestuPasaribu. 2009. Edema PatofisiologidanPenanganan.
(ed). BAIPD. Jilid I. Edisi IV. Jakarta : FKUI.Pages 515-517
10. Haddad, Lawrence. 2011. The right ingredients : the need to invest in child
nutrition. UNICEF : UK. [diakses tanggal:5 mei 2016] URL :
https://www.unicef.org.uk/Documents/Publicationpdfs/UNICEFUK_ChildNut
ritionReport2013w.pdf

11. Citrakesumasari. 2012. Buku Ajar Anemia Gizi, Masalah, dan

Pencegahannya. Yogyakarta: Kalika. Pages 8-9

12. Fediani, Tami. 2012. Hubungan Tingkat Pengetahuan Ibu Dengan Tindakan
Ibu Terhadap Kejadian Diare Pada Balita Di Kelurahan Tanjung Sari Tahun
2011. Medan: USU. Pages 4-5
13. Ilyas, Sidarta. 2009. Ilmu Penyakit Mata. Jakarta : Balai Penerbit FKUI
14. Sylvia Anderson Price, dkk. Patofisiologi : Konsep Klinis Proses-Proses
Penyakit. Jakarta : EGC
15. Isselbacher, dkk. Harrison Prinsip-Prinsip Ilmu Penyakit Dalam, Jakarta :
EGC
16. N Jafar. 2012. Carbohydrate and Protein Deficiency in Toddlers incidence of
malnutrition. Nutritional Science Faculty of Public Health, University of
Hasanuddin Makassar.
17. Goetz LH. 1986. Malnutrition and immunological function with special
reference to cell-mediated immunity. Am J Physic anthropol
18. Masnjoer A, dkk. Kapita Selekta Kedokteran. Edisi III. Jilid II. FKUI. Jakarta.
2000; 514-18.
19. http://carenlee.newsvine.com/_news/2012/02/24/10493691-marasmus-causes-
symptoms-and-treatments

20. Pedoman Pelayanan Medis Ikatan Dokter Anak Indonesia (IDAI) Edisi 1 2009

21. Pedoman Pelayanan Medis Ikatan Dokter Anak Indonesia (IDAI) Edisi 2 2011
22. Al Quran dan Hadits